Provider Demographics
NPI:1205884590
Name:ANTHONY, VATTI THECKLA (MD)
Entity type:Individual
Prefix:DR
First Name:VATTI
Middle Name:THECKLA
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5652
Practice Address - Street 1:2392 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3310
Practice Address - Country:US
Practice Address - Phone:772-223-5628
Practice Address - Fax:772-223-5652
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135162207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024761200Medicaid
FLVVN40OtherFLORIDA BLUE
MD499585OtherNCCPO PROVIDER NUMBER
MD68635203OtherBSMD PROVIDER NUMBER
MDP16994OtherCAREFIRST POS
MD8140391OtherMDIPA PROVIDER NUMBER
MD8140391OtherMAMSI PROVIDER NUMBER
MD521186611OtherUNITED HEALTHCARE PROV #
MD8140391OtherALLIANCE PROVIDER NUMBER
MD8140391OtherMAMSI PROVIDER NUMBER
MD8140391OtherALLIANCE PROVIDER NUMBER
MD521186611OtherUNITED HEALTHCARE PROV #